1. Field of the Disclosure
The present disclosure relates generally to management of healthcare processes, and in particular development of specific actions for specific healthcare resources based on knowledge that can be determined from historical data about such resources.
2. Description of the Relevant Art
Virtually all work within a business gets done via a process. In general, there are multitudes of employees (or agents), systems, and information involved in the processes critical to any business. For example, healthcare delivery includes processes for treatment of patients by physicians, maintenance of medical histories for the patients, and billing for the healthcare services provided to the patients.
Healthcare today is like many other stressed industries, in that change and improvement are an essential reality. This is not just for those firms and organizations facing impending insolvency or cash flow crises, but also those striving to improve their efficiency, profitability, and competitiveness. Change initiatives are the way to achieve these improvements. It is important to realize, however, that these change and improvement initiatives have a limited window of opportunity to succeed, lest they damage themselves and all other initiatives “downstream” from them. Consequently, time is of the essence in incorporating business process improvements.
Proper execution of a business process requires actions to be performed by multiple employees or agents of the business (hereinafter referred to as “roles”). Processes with high levels of complexity, such as those within healthcare delivery, may suffer cost overruns, quality deficits or other process breakdowns. A process breakdown occurs when a ‘role’ fails to perform a task or ‘action’ that leads to a loss of revenue or imposes a cost on the business. In other words, process breakdowns are the result of failure to execute the best available ‘role-action.’
For example, hundreds of millions of dollars of revenue are lost per year, and millions of dollars in fines are levied by regulators in the healthcare industry due to inadequacies in the clinical documentation process of billing for healthcare services. This problem has persisted because there has not been a cost-effective process in place to adequately review and cross reference patient billing and medical records. Furthermore, there has not been a cost-effective process to document diagnoses and treatments vis-a-vis all of the clinical information to determine if there are any documentation gaps or opportunities that physicians should note in patient records prior to billing.
One reason that process breakdowns occur is that businesses are frequently overwhelmed with reams of data generated by the various systems and roles involved in performing the individual role-actions within a business process. Managers and other roles often lack the resources necessary to properly review, analyze, and act on this information. These necessary resources include time, information, motivation, skill, and authority to act on the generated data.
One typical strategy for attempting to reduce process breakdowns is additional training for roles within a business. Such training may include introduction of new technology (e.g. software solutions) into the business with the goal of improving efficiency. Unfortunately, training individuals to use new technology is extremely challenging and frequently ineffective. Often this ineffectiveness is related to the same lack of resources (time, information, motivation, skill, authority) creating the process breakdown.
For example, physicians are routinely faced with pressures on their time. This lack of time can result in a physician failing to record all of the information necessary to allow the healthcare organization to use the highest justifiable value billing code for the physician's activity. Additionally, the physician's motivation is to focus on treating the patient, not on recording billing information. Simply training the physicians to understand the billing system will not necessarily improve this situation, as providing the physician with generalized billing information does not address the potential lack of time or motivation to address the problem. Co-pending U.S. patent application Ser. No. 10/751,192 and the applications related thereto disclose techniques to review all of the records and information related to a patient, and present the physician with a crystallized finding for his/her consideration so that opportunities for use of higher value billing codes may be identified. These applications further disclose methodologies for identifying process breakdown points within a business process and assigning role-actions (tasks for individual roles) that will improve or replace the role-action leading to the breakdown.
Challenges remain, however, for further improving efficiency in healthcare processes. Discovering, implementing and revising process improvements successfully are not accomplished often enough to maximize the effectiveness of typical facilities. Known approaches involve hiring consultants to conduct staff interviews, analysts to conduct time/motion studies, or committees to undertake reengineering projects. These approaches can lead to improvements, but generally take a great deal of time and effort to implement, including disruption to existing operations. For example, many reengineering approaches attempt to improve processes by starting from scratch and developing new processes without regard to what existing processes are being used. As a result, process improvement is oftentimes not embraced by staff and improvement falters.
What is still needed is a system for transparently improving processes in a manner that minimally disrupts staff, quickly leads to improvements, and provides a high return on the investment in process improvement effort.